Guyatt G H, Sinclair J, Cook D J, Glasziou P
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
JAMA. 1999 May 19;281(19):1836-43. doi: 10.1001/jama.281.19.1836.
Clinicians can often find treatment recommendations in traditional narrative reviews and the discussion sections of original articles and meta-analyses. Making a treatment recommendation involves framing a question, identifying management options and outcomes, collecting and summarizing evidence, and applying value judgments or preferences to arrive at an optimal course of action. Each step in this process can be conducted systematically (thus protecting against bias) or unsystematically (leaving the process open to bias). Clinicians faced with a plethora of recommendations may wish to attend to those that are less likely to be biased. Therefore, we propose a hierarchy of rigor of recommendations to guide clinicians when judging the usefulness of particular recommendations. Recommendations with the highest rigor consider all relevant options and outcomes, include a comprehensive collection of the methodologically highest quality data with an explicit strategy for summarizing the data (that is, a systematic review), and make an explicit statement of the values or preferences involved in moving from evidence to action. High rigor recommendations come from systematically developed, evidence-based practice guidelines or rigorously conducted decision analyses. Systematic reviews, which typically do not consider all relevant options and outcomes or make the preferences underlying recommendations explicit, offer intermediate rigor recommendations. Traditional approaches in which the collection and assessment of evidence remains unsystematic, all relevant options and outcomes may not be considered, and values remain implicit, provide recommendations of weak rigor. In an era in which clinicians are barraged by recommendations as to how to manage their patients, this hierarchy provides a potentially useful set of guides.
临床医生常常可以在传统的叙述性综述以及原创文章和荟萃分析的讨论部分找到治疗建议。提出治疗建议涉及构建一个问题、确定管理选项和结果、收集和总结证据，以及应用价值判断或偏好来得出最佳行动方案。这个过程中的每一步都可以系统地进行（从而防止偏差），也可以非系统地进行（使过程容易出现偏差）。面对大量建议的临床医生可能希望关注那些不太可能有偏差的建议。因此，我们提出了一个建议严谨性的等级体系，以在临床医生判断特定建议的有用性时为其提供指导。严谨性最高的建议会考虑所有相关选项和结果，包括全面收集方法学上质量最高的数据，并采用明确的数据汇总策略（即系统评价），还会明确说明从证据到行动所涉及的价值观或偏好。高严谨性的建议来自系统制定的、基于证据的实践指南或严格进行的决策分析。系统评价通常不考虑所有相关选项和结果，也不明确建议背后的偏好，提供的是中等严谨性的建议。证据收集和评估仍不系统、可能未考虑所有相关选项和结果且价值观仍不明确的传统方法，提供的是严谨性较弱的建议。在一个临床医生被关于如何治疗患者的建议所淹没的时代，这个等级体系提供了一套可能有用的指南。
